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Improving rural medicine

The Wright Rural Health Initiative has grown to unexpected heights since beginning in 2012 under the leadership of Robert Gill, M.D.

June 13, 2018

Vital Signs » Summer 2018

All around the United States, rural areas struggle to attract physicians. There are simply not enough doctors to provide the care needed. It’s an issue in desperate need of a solution. But so far, only a handful of medical schools in the country have made a commitment to underserved rural areas.

In 2012, the Wright State University Boonshoft School of Medicine was one of the first, pioneering a new effort in areas around the university’s Lake Campus, located in Celina, Ohio, about 80 miles northwest of Dayton, Ohio. It has since grown in ways unimaginable at its beginning. At the time, it was just a country doctor’s dream. Today, it is the Wright Rural Health Initiative (WRHI).

You might call Robert Gill, M.D., a visionary. But even he didn’t know what his efforts to launch the program would yield. He was just a thoughtful man with good intentions hoping to preserve a high level of care for his patients of almost 30 years. It was time for him to retire, but who would they turn to for care?

Gill, who ran a private family care practice in the area, had scant options. He could hire a new physician himself, which would risk his retirement funds, or he could ask around to see what the nearby medical school could provide.

“We started to talk about how we could bring the students out here,” Gill said. “I started bringing some medical students out to rotate with me. At that point in time, I developed a more formal relationship with Wright State’s medical school and became assistant clinical professor.”

He retired from private practice and began working for Grand Lake Health System, where he would later become chief medical officer. Gill realized that there was no way he could do it alone. He started to recruit other physicians to also act as preceptors for medical students, many from the health system.

Leaders at the Boonshoft School of Medicine also answered the call. Dean Margaret Dunn, M.D., M.B.A., helped the expansion effort. So, too, did John Pascoe, M.D., M.P.H., professor of pediatrics and director of pediatric health services. Also involved were Dean Parmelee, M.D., professor of psychiatry and pediatrics and director of educational scholarship and program development, as well as Marjorie Bowman, M.D., M.P.A., professor of family medicine and professor of population and public health. Therese Zink, M.D., M.P.H., former chair of the Department of Family Medicine, helped move things forward as well.

The administration of Grand Lake Health System welcomed medical students to its different practices, and more and more doctors began serving as preceptors. Another health system in the region, Mercer Health, joined the effort later on.

“Over a period of several years, Grand Lake and Mercer Health systems have led the way as far as establishing students coming out here to our rural setting,” Gill said. “Because we all realize we’re going to need an influx of physicians in order to fill the gaps when the older physicians retire.”

The first students rotated through the WRHI beginning in 2013. It was a novel track, and only a few students signed up. Since then, it has become apparent that there are substantial benefits to those who journey to the area and live at Wright State University Lake Campus.

Gill has heard nothing but good things from the third-year medical students he’s helped to mentor. They’ve discovered the numerous advantages that practicing in a rural area provide.

The biggest one is that they get personal attention from preceptors. In urban areas, the situation is much different. In the rural setting, the students also get a broader base of experiences, and are entrusted with more responsibilities earlier on.

“The learning curve is very steep at first, but they pick up pretty quick on the knowledge base,” Gill said. “There can be one-on-one communication with a doctor when the student sees the patient. The students rotating out here are third-year medical students. Often, they’re right out of their didactics and at the beginning of the year they’re a little less experienced. By the end of the year, they have a lot more experience.”

The region has less traffic than a large, urban center and is very safe. The patient population is also its own mix.

“When you’re living in farming communities in the rural area, you may see a little different spectrum of injuries and things that you may not see in a city setting,” Gill said.

It’s a close community, one where doctors work for decades, forming relationships that go far beyond that of physician and patient. It’s common to see friends at the grocery store instead of the doctor’s office. There’s a stronger bond because everyone is a member of the same village.

Gill knows the feelings and commitment that working in a rural area can inspire. A native of Salina, Kansas, who attended the Medical College of Ohio, his work settled him near Celina, Ohio. It was a natural and welcome fit for a man who worked his way through college as a construction worker building grain silos and other icons of farming life.

The opportunity to come out and work in the rural area is a rare one, as much of the tracks in medical education run through big urban centers in large hospitals.

“As a result, your exposure to rural medicine is pretty limited. So this is a way to expose the medical students as to what’s available in a rural setting, to show them how you practice in a rural setting,” Gill said. “This allows them to see that there are some very positive benefits.”

In just a few years since the beginning of the Wright Rural Health Initiative, third-year students at the Boonshoft School of Medicine have noticed the unique opportunity. For the 2017-18 academic year, 18 students completed 32 rural clerkships, with some students doing as many as four of their six clerkships at rural sites.

One of the lucky few to snag a spot is Jessica Uhler, who is entering her fourth year of medical school. As she grew up in rural West Harrison, Indiana, Uhler has always felt a draw toward practicing in a rural region. One of the main reasons she chose to attend the Boonshoft School of Medicine was the Wright Rural Health Initiative. Her rotations in the Lake Campus area have proven to be as fruitful as she’d hoped.

“I really enjoyed working directly with attending physicians on my rural clerkships as opposed to being with lots of other students and residents when you rotate in Dayton,” Uhler said. “My pediatric outpatient rotation with Dr. Melanie Jungblut of Mercer Health was a formative rotation for me. It really affirmed my decision to go into family medicine because I really enjoyed working with pediatric patients. Dr. Jungblut also exemplified the type of physician I'd like to be. She always practiced with compassion and went above and beyond for her patients to find the limited resources available in a rural area.”

Uhler noticed that her preceptors often would start a task or manage conditions that would usually be done by specialty physicians in an urban area. Those specialists aren’t as available in rural areas, so there were numerous opportunities to broaden her scope of expertise.

The largest difference she noticed was the extent to which rural physicians are known in the community. There are deeper and more significant relationships between doctors and patients, which can benefit the level of care provided while also making work challenging. The dynamic intrigues Uhler.

“Over a period of 30 years, you develop relationships with your patients beyond the patient-physician interface,” Gill said. “Some of them become your friends. You spend time with them. You see them in the community.”

It revealed itself through the gratitude shown by patients who have seen her during rotations.

“I was genuinely surprised during my first rotation by how many patients actually wished me luck with my schooling and thanked me at the end of their appointments,” Uhler said.

The experience was similar for Jerika Ortlieb, M.D., ’18. Through her two rotations in third year, Ortlieb was convinced that family medicine was the specialty for her.

The first one came unexpectedly, as Ortlieb initially wanted to stay in Dayton for her first rotation to be closer to her husband and dogs. She was already nervous and didn’t want to add the extra stress of living apart. But a Dayton doctor was unable to take her on, and she was placed in Wapakoneta, Ohio, with Parmie Herman, M.D.

“It turned out to be my favorite rotation by far and had a huge influence on my specialty choice. After my first rotation, I signed up for the rural surgery clerkship as well,” Ortlieb said. “Working in a rural area is an enriching experience for the physician that allows you to practice broader scopes of your chosen field and build meaningful relationships within your community and with your patients.”

In her second rotation, she saw the flexibility required by rural surgeons. These surgeons work in general surgery, trauma, gastroenterology, as well as women’s health. It’s common to have full family units seen by the same provider and people using the same surgeon for different types of surgeries.

She learned those and other approaches from the physicians she shadowed. Her family medicine rotation took her to a practice run by a doctor couple who married and took over a practice from the husband’s father.

“The patients were more than two-dimensional numbers in the charts. They had families, jobs, and hobbies that their doctors played an integral part in,” Ortlieb said. “It was like the cases and conditions I had been studying for so long suddenly had names and faces. The field of medicine overwhelmingly became full of depth and life.”

The physicians she shadowed opened up all the possibilities of working in rural medicine. They helped her find confidence and pushed her to improve each day.

As the WRHI grew, Family Health Services of Darke County and Mercy St. Rita’s Medical Center in Lima, Ohio, began taking students regularly. Most of the physicians who serve as preceptors are employed by one of the area’s health systems. There are some in private practice, but that is becoming less common as costs for maintaining a solo practice have risen over the years.

The physicians in the area have been very generous with their time and teaching Wright State medical students. It’s a positive thing for the medical students and a very good stimulus for practicing physicians who are able to train future doctors.

“The reimbursement factor is the thought that you might be training one of your future colleagues. You never know if one might come back and practice with you, which is the hope that we have, is that some of these will come back and practice here,” Gill said. “They can see that our living situation is good. They can see that we practice good medicine, surgery, obstetrics and gynecology, and the people are nice and we treat them well. Even if they don’t come back here, and they go to a rural setting, we are still fulfilling a need to get doctors into the rural areas.”

The Boonshoft School of Medicine is one of only a handful of medical schools in the United States that supports a rural health initiative. A little more than five years in, the Wright Rural Health Initiative has grown more than Gill anticipated.

The program has brought together likeminded students and care providers who are helping to fill a critical need. Who knows where the program will go in the future, but the first step was taken by Gill, a doctor from Salina, Kansas, who found a new home in Celina, Ohio.

“You never know where something is going to go. All you can do is just try,” Gill said. “If your intentions are good, and if you want to try to do something that’s positive, and you have people who are willing to go with you and donate their time, and see that it is a worthwhile purpose, a lot of the time it goes in a very positive way.”